VOLUNTEER APPLICATION
_______________________________________ _____________________________________
Name
Date of Birth
_______________________________________ _____________________________________
Social Security Number
Phone Number
______________________________________________________________________________
Home Address
______________________________
City, State
___________________
Zip
_______________________________________
E-mail Address
_______________________________________ _____________________________________
Emergency Contact
Relationship to Applicant
_______________________________________
Emergency Phone Number
EMPLOYMENT
_______________________________________ _____________________________________
Employed By (If Employed)
Phone Number
______________________________________________________________________________
Address
May you be called at work?  Yes
 No
Brief description of work: ________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org
EDUCATION
Formal Education (highest year of school completed): ______________________________
Do you speak a foreign language?  Yes  No
If yes, which language: _____________
AVAILABILITY
Are you comfortable using a computer to fulfill your volunteer duties (typing and emailing
court reports)?
 Yes  No
Do you have access to a secure computer either at work or at home?
Do you drive?  Yes  No
 Yes  No
Do you have regular access to a car?  Yes  No
Current community activities: ___________________________________________________
______________________________________________________________________________
______________________________________________________________________________
List current and previous volunteer work (list all previous volunteer work including brief
description of duties and activities, dates of service.):
______________________________________________________________________________
______________________________________________________________________________
As a CASA volunteer you will be required to attend court hearings for the children you
represent. These hearings occur on Monday or Wednesday afternoons. Will you be able to
arrange your schedule to attend these hearings?
 Yes  No
Are you willing to commit to one year of volunteer service?  Yes  No
MOTIVATION
What are your reasons for wanting to participate as a CASA volunteer?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org
Have you had any personal experience(s) involving:
 Child Welfare
 Foster Care
 Court System
 Other agencies offering services to a child
If so, please explain: ___________________________________________________________
______________________________________________________________________________
How did you learn of our program: ______________________________________________
______________________________________________________________________________
BACKGROUND
Have you ever been convicted of a crime other than a traffic violation?  Yes  No
If yes, what charge? __________________ Date convicted: ________ Where ____________
Do you consent to a routine check of your criminal records?  Yes  No
Can you think of any reason why a judge might be reluctant for you to serve as a CASA
volunteer?
___________________________________________________________________________
How long have you been a resident of Boyle/Mercer County? ______________________
How long have you been a resident of Kentucky? ________________________________
If you have lived in the state of Kentucky for less than five years, please provide us with the
complete address of your last residence outside of Kentucky:
Street address__________________________________________________________________
City____________________________ State__________________ Zip Code ______________
CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org
Character References
Please list three character references that have known you for at least two years and are NOT
related to you by blood or marriage. Complete addresses are REQUIRED.
1.
Full name __________________________ Phone _____________________________
Street Address___________________________________________________________
City ___________________________ State ____________ ZIP Code _____________
What is your relationship with this person?___________________________________
How long have you known this person? ______________________________________
2.
Full name __________________________ Phone _____________________________
Street Address___________________________________________________________
City ___________________________ State ____________ ZIP Code _____________
What is your relationship with this person?___________________________________
How long have you known this person? ______________________________________
3.
Full name __________________________ Phone _____________________________
Street Address___________________________________________________________
City ___________________________ State ____________ ZIP Code _____________
What is your relationship with this person?___________________________________
How long have you known this person? ______________________________________
CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org
PLEASE RETURN YOUR COMPLETED APPLICATION ALONG WITH A PHOTOCOPY OF
YOUR DRIVER’S LICENSE TO:
CASA at Woodlawn
1153 Perryville Road
Danville, KY 40422
(859) 936-3510
fax: (859) 936-3562
Please read the following statement before signing:
I hereby certify that all information on this application is true and correct to the best of my knowledge. My
signature below authorizes CASA at Woodlawn to make necessary checks to determine suitability to serve as a CASA
Volunteer. This may include, but is not limited to, character reference checks, child abuse/neglect records, criminal
records, sex offender registry checks and other individuals or agencies that may have knowledge of the applicant.
These checks will be conducted before service begins and periodically for the duration of the volunteer’s service. All
information collected will be held in the strict confidence. I understand that the program reserves the right to reject
this application for any reason; and that any convictions or pending charges involving a sex offense, child
abuse/neglect or related acts that in the program’s judgment would pose a risk to children or the program’s
credibility, will result in the rejection of my application.
_______________________________________________ Date ________________________________
(Applicant’s Signature)
This section to be completed by CASA personnel only:
CAN Registry:
__________ Sent
__________ Received
AOC Records:
__________ Sent
__________ Received
Sex Offender Registry:
__________ Sent
__________ Received
Out of State Records:
__________ Sent
__________ Received
(if applicable)
Character References:
Received:
__________ Sent
1. __________
Interview held:
2. __________
____________________
(date)
Training completed: ____________________
(date)
Badge made:
3. __________
by _______________________________
Oath taken:
______________________
(date)
____________________
(date)
Application reviewed and certified complete by: _________________________________
(signature of CASA personnel)
CASA at Woodlawn is committed to a policy of providing volunteer opportunities to all qualified
people regardless of economic or social status and will not discriminate on the basis of race,
color, ethic origin, national origin, creed, religion, political belief, sex, sexual orientation,
marital status or age. CASA at Woodlawn is an equal opportunity agency. We encourage
applications from women, minorities, and all interested and qualified people.
CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org
CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org
CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org
CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org
CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org